In 2022, the path to Medicare Advantage (MA) Star Ratings success will become more challenging. MA plans must contend with an ongoing pandemic (without the relaxed rules of the prior performance year) while simultaneously meeting ambitious goals around medication adherence and member satisfaction.
As adherence measure cut points have continued to rise approximately 2% per measure per year, the highest-risk, nonengaged members are becoming a focal point to maintain adherence performance. Further, entering this year’s performance period, MA plans need to address higher-risk patients differently for medication adherence measure improvement.
In the past, health plans may have gotten by with a broad-strokes approach to outreach and one-way, transactional interactions with members. But plan/member relationships need to evolve to support individualized needs to overcome barriers to care.
Thanks to triple-weighted adherence measures and a host of medication-related Part C and Part D measures, more than half of a health plan’s Star Ratings score depends on medication management performance. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) member experience surveys now account for a third of MA plans’ Star Ratings. Overall, the MA Star Ratings are heavily skewed toward these areas, more than in past years, with over 80% of the weighting.
With industry reputation and billions in quality bonuses at stake for health plans, MA stakeholders cannot afford to be stagnant with their medication adherence and member engagement approach. Plans must make medication management their top priority, particularly for unengaged individuals at greatest risk of falling away from their recommended treatment plans—and consequently reporting negative experiences in CAHPS surveys.
To see success in these complementary areas, MA plans need to better understand how technology can be used to guide member outreach and successfully engage consumers in the quest to address the challenges of medication adherence.
Understand Medication Adherence Goals Within the MA Star Ratings System
The MA Star Ratings system considers a member “adherent” if they have access to their medications for at least 80% of the plan year. Members who fall below this proportion of days covered (PDC) are considered guaranteed nonadherent for the applicable performance period.
Achieving 80% PDC for the plan year requires a longitudinal commitment. This commitment begins with the first fill of a medication and requires behavioral consistency that must persist through the end of the year. In fact, because members must have 2 medication fills to qualify for the star measure, they can fall into a state of nonadherence prior to their second fill (before they are even measure qualified). As such, the adherence journey involves vulnerability from beginning to end.
Prioritize High-risk members for Targeted Outreach
MA plans can start by embracing data-driven technologies to identify high-priority, high-risk individuals at the beginning of a new measurement period.
Plans can best target individuals using advanced analytics generated from multiple, disparate data sources (eg, pharmacy, eligibility, quality/Healthcare Effectiveness Data and Information Set [HEDIS], hospital discharge, social determinants of health [SDOH]) to prioritize vulnerable populations most at risk for nonadherence. These higher-risk patients will benefit from personalized outreach that addresses their unique barriers of care to advance medication adherence. Higher-risk patients typically share some of the following characteristics:
- Previously nonadherent or borderline adherent in the prior year
- Members with known socioeconomic challenges such as food insecurity, transportation barriers, or residence in a pharmacy desert
- New plan members or members with new prescriptions who do not yet have a history of guaranteed adherence
- Members with multiple chronic conditions and/or polypharmacy (5 or more prescriptions)
Health plans should prioritize outreach to these higher-risk members who fall into 1 or many of these categories—and this outreach should take place year-round, with the goal of engagement top of mind.
Develop Relationships Aimed at Addressing Member Needs
Once health plans have developed a target list of high-risk members, they should use data and insights from predictive analytics to guide conversations as they conduct proactive outreach aimed at promoting engagement. Integrating advanced analytics in a customer relationship management (CRM) tool supports patient outreach by automatically generating workflows that themselves generate alerts on existing gaps in care and triage barriers to care based on real-time data.
These alerts are aligned with quality measures—thus providing more meaningful, impactful interactions.
It is essential to recognize that outreach and engagement are, in fact, very different. Outreach is transactional in that it is a one-way communication that informs members about an issue, problem, opportunity, or decision. Engagement goes beyond that.
Engagement opens a personalized discussion with members, allowing them to express their thoughts, feelings, and concerns about environmental issues beyond their prescription drugs. Successful engagement builds meaningful relationships with members and results in them taking part in informed, shared decision-making about their health. Like other interventions, engagement should focus on helping members resolve concerns and result in lifestyle changes that positively affect health outcomes and utilization; for example, adhering to diabetes medication to control high blood pressure and prevent complications such as diabetic ketoacidosis.
Telepharmacy outreach that leverages motivational interviewing is an essential strategy for stimulating member engagement and eliciting behavior change. However, the tactic is often time consuming and usually requires an experienced facilitator who understands how to motivate high-risk members to work toward a goal. Complicating matters, the root of a patient’s lack of engagement or hesitancy to make healthy choices is often tied to nonclinical factors, such as social or economic factors.
Tips for Successful Engagement
- Leverage predictive analytics to identify high-risk members
- Conduct proactive outreach year-round, leveraging purpose-built telepharmacy clinical software workflows in an integrated holistic customer relationship management platform
- Leverage social and community resources coupled with available health plan benefits to solve for social determinants of health
- Build on the relationship throughout the year; use what you’ve learned to keep engaging and eliciting change
- Collect data to create a continuous learning loop that can help promote future engagement
- Use trained clinicians to manage engagements that integrate motivational interviewing into conversations to identify barriers to care and resolve them on the spot
For example, perhaps a chronically nonadherent, nonengaged member has not taken their medications because there is no food in their refrigerator. If given the choice between food security and taking prescription drugs, the decision is obvious. One could consider this the Maslow Hierarchy of Needs (for health care): food, shelter, access, health literacy, vaccination hesitancy. These SDOH problems cause nonadherence and need to be addressed to change the trajectory for health outcomes. Further, these are the same members who are reporting poor experience issues in CAHPS surveys and potentially churning from the plan membership.
This is why integrating qualified clinicians with motivational interviewing skills and training in SDOH is crucial for engagement. These activities should be rooted in the telepharmacy where qualified clinical professionals can deliver education, answer questions about specific medications, and coach members toward better adherence.
Digital telepharmacy teams need data-driven clinical software tools to overcome individual barriers of care, including educating members about available health plan benefits, leveraging online community resource directories to offer socioeconomic support, and easing barriers to medication access through medication synchronization compliance packaging or home delivery. This strategy is most effective with a technology platform that consolidates all member quality measure gaps and builds on discrete data capture that documents patient and provider feedback from the patient engagement. Appending this structured engagement feedback to the digital record of the patient enables artificial intelligence to create the “next best action.”
Develop Sustained, Meaningful Relationships With Members Throughout the Year
Technology is critically important for health plans that cater to underserved populations. Health plans can’t rely on one-and-done interactions with their nonadherent members, particularly their high-risk populations. A single transactional conversation at the beginning of the year isn’t enough to support high-risk members throughout the year to build quality momentum—and plans have very narrow margins of failure when it comes to meeting Star Ratings medication adherence measures.
Higher-risk patients with medication adherence issues need multiple touchpoints throughout the year to ensure they continue taking their medications as prescribed. Data-driven insights embedded in telepharmacy software workflows can render this outreach much more personalized and effective, which is crucial for promoting engagement. Plans should establish a data-driven cadence of telepharmacy outreach based on daily data updates that include patient-provider engagement responses based on individual support needs. A CRM-like system can center holistic quality improvement to overcome barriers of care throughout the year.
Again, establishing strong partnerships with digital telepharmacy experts can significantly boost capacity. Collaborating with partners for higher-risk engagement ensures plans have access to highly trained telepharmacy clinicians with the technology, knowledge, and experience to enact sustainable change. These clinicians should have access to advanced technologies capable of processing a myriad of health care data and understand how best to leverage the insights from those data while taking a person-centered approach to interactions. Motivational interviewing is crucial to evoke more in-depth responses to questions. For example, asking “How can we help you get back on your medication?” is often more effective than telling someone, “Take your medication so you don’t end up in the emergency department.” The former helps uncover the root cause of adherence issues by understanding and addressing barriers of care.
A recent multiyear study conducted by AdhereHealth demonstrated that tech-enabled telepharmacy engagement produced measurable results for patients. AdhereHealth partnered with a large 200,000-plus MA regional health plan and focused on MA Star Ratings adherence measures for 37,748 high-risk patients. Some members were new to the plan while the majority had less than 84% PDC in the prior measurement year. Data showed AdhereHealth successfully engaged these high-risk members for multiple years (2017-2020). The connect rate with this unengaged, or new, cohort was 54.06% thanks to a targeted telepharmacy outreach. AdhereHealth’s telepharmacy spent an average of 16.4 minutes of talk time with those members, which led to 18,161 conversions and a 29.7% gap closure rate, ultimately averaging 4.5 stars on medication-related CAHPS scores for the 4 years measured.
Medication-Related Measures and CAHPS
To support better CAHPS scores and improved experiences overall, foundational adherence outreach should take a holistic view of each member’s health and incorporate any other medication-related HEDIS quality measures.
For example, health plans are held to high standards for ensuring that diabetic members are adherent to their medications (D10-Medication Adherence for Diabetes Medications) and that they have their blood sugar under control (C15-Diabetes Care—Blood Sugar Controlled). Because blood sugar is typically managed with the help of medications, ensuring that members have access to their prescriptions can support higher performance on multiple measures. Moreover, these same diabetic members may also qualify for needing a statin (D14-Statin Use in Persons with Diabetes) and a host of other Star Rating measures. When there is opportunity to engage, building quality momentum with the individual should include addressing all relevant Part C and Part D medication-related measures. This approach ultimately improves CAHPS member experience measures as well.
New Medication Adherence Measures
Complementing existing Part D Star Rating health plan adherence measures, the Pharmacy Quality Alliance (PQA) recently endorsed a new pharmacy composite adherence measure for diabetes medications, hypertension, and cholesterol. PQA will also develop a health plan composite adherence measure in the future that could be adopted by CMS for future Star Ratings measurement, as CMS seeks to amplify its focus on adherence outcomes improvement.
Amazingly, about half of Americans don’t take their chronic long-term therapy medications as prescribed, leading to over $500 billion in avoidable health care costs and more than 125,000 potentially preventable deaths. Otherwise stated, over $500 billion a year and 16% of the nation’s overall health care spend annually represent avoidable utilization cost due to nonadherence to medications. There is a clear and urgent need for health plans to support members at risk of falling short on adherence outcomes. Since members who have their health under control tend to be happier with their health care services, plans will likely score better on CAHPS measures. Lastly, it is obvious these improvements will consequently reduce member attrition from unsatisfied customers as well.
By investing in data-driven, telepharmacy-led engagement, MA plans can achieve higher Star Ratings. The result is higher member satisfaction and financial opportunities to provide better benefits to members.
This article has been updated.
Jason Z. Rose, MHSA, is CEO of AdhereHealth.